History of Present Illness Help

Esme12, ASN, BSN, RN · Mar 15, 2014

every persons journey is individual. what brought her to the hospital? Were you able to look at her transfer/COBRA record from the hospital? Why was she admitted to the SNF? Is she no longer able to be at home? Can she no longer be trusted to care for herself?

MusicEMT · Mar 16, 2014

every persons journey is individual. what brought her to the hospital? Were you able to look at her transfer/COBRA record from the hospital? Why was she admitted to the SNF? Is she no longer able to be at home? Can she no longer be trusted to care for herself?

Thank you for your reply Esme! your posts are very imformative and quite helpful!

She doesn't have a Transfer/Cobra record

So a bit more background on the patient: She was brought in Yellow Cab Taxi and Was living with her sister, she is S/P CVA and has Left sided hemaplegia and also due to her Alzheimer disease is unable to care for her self in her History of present illness do we also list her past history to and how it plays into her current condition?

Esme12, ASN, BSN, RN · Mar 16, 2014

You just described her history of present illness.

This is a 83 year old (insert ethnic group) female with a previous history of HTN, Esophageal Reflux, Depressive Psychosis and Alzheimer's Disease. She is S/P CVA and has Left sided hemaplegia . She presented to (insert name here) a skilled nursing facility via yellow cab. This patient had been living at home with her elderly sister until (insert date) when it became clear that the sister can no longer assist the patient and the patient cannot effectively participate in her care due to her advanced Alzheimer's disease.

Now you can describe what changed at home and how she has advanced recently if you have that information. If you don't know then you describe the patient now.

The patient presents....(insert physical assessment) [pale, thin, elderly female that is (insert description...well kept, unkempt,)etc} Patient is not oriented to time, has poor memory, confused...blah blah blah with L sided impairment/paralysis (does she walk?)...insert physical assessment here. Her current meds are...blah blah blah.

Now....I don't know what your instructor wishes....I did have students describe, "look up" diseases, pathophys, how they are associated with present situation or contribute to the present situation...and reference to them in their descriptive statement. As well as looking up the meds and her diagnosis/disease. They always sighed, moaned, and rolled their eyes ...but appreciated it later for it clearly helped them as they moved forward towards independent critical thinking.

It this what you are looking for?

dudette10, MSN, RN · Mar 16, 2014

When you get stuck on something like this, it helps to look at examples. Did you review the H&P by the admitting MD or the ER doc? I'm not suggesting you plagiarize his/her work, but HPI is critical to medical diagnoses, so their examples can help you out. If you are concerned with unintended plagiarism, you can always ask to see a classmate's patient's H&P as an example.